Contraception during Perimenopause

Many women say that the best thing about menopause is that they need no longer worry about contraception. It’s true! But what is the best method of contraception if you’re between thirty-five and meno­pause? It is interesting to note that what may be a good contraceptive when you are young may not be as good when you are older.

Since women are less fertile in the later reproductive years, a contra­ceptive method that might have been 90 to 95 percent effective when you were twenty might prove to be almost 100 percent effective when you are 40. A simple barrier method, like the diaphragm, that you were worried about using in your younger years because of its poten­tially high failure rate, might be a good method later in life. Whatever method you choose, always discuss it with your family practitioner or gynecologist. To give you an overview, however, here are some important facts for women over the age of thirty-five about four different methods of contraception.

The Pill (The Combined Estrogen-Progestin Birth Control Pill)

Beginning in the late 1960s, several major studies were published suggesting that older women who use oral contraceptives (OCs) are at an increased medical risk. Subsequently, women didn’t want to take the pill, and physicians would often refrain from prescribing them. Most of these studies concluded that older women using OCs were at higher risk of heart attacks, hypertension, strokes, and overall mortal­ity. But these studies did not look at cigarette smoking, preexisting high blood pressure, and other factors that increase the risk of cardio­vascular disease, nor did they differentiate between the various kinds of birth control pills that were being prescribed. Indeed, virtually all the clinical studies were of women using the high-estrogen OCs that have practically disappeared from the market.

The new generation of pills, which have far less hormone in their formulation, are quite different. Another factor, not taken into ac­count, is the potential health benefits of OCs, which include appar­ently reduced incidences of uterine and ovarian cancer, pelvic in­flammatory disease (PID), anemia, and rheumatoid arthritis. Other benefits may include a reduced risk of fibrocystic and other benign breast diseases, improved menstrual cycle control, and relief of PMS, which tends to become more severe after the age of thirty-five. These facts are establishing a strong school of thought, teaching that a woman can continue taking an OC as long as she remains in good health and has no signs of hypertension, late-onset diabetes, uterine lining abnormalities, or other complications. It is also necessary that she have an annual medical screening with a comprehensive physical examination including a blood pressure check, pelvic examination, abdominal palpation, and cholesterol testing. If there is a family his­tory of diabetes, then blood sugar testing is also recommended.

In September 1989, a report from the Harvard Nurses Health Study that appeared in the Journal of the National Cancer Institute of­fered the greatest reassurance. It noted that women over age forty who have used oral contraceptives do not have an increased risk of breast cancer, even if they used them for prolonged periods of time.

As women age, however, there are certain other contraindications to taking the pill. A history of cardiovascular disease, liver cancer, breast cancer, diabetes, hypertension, obesity, or uterine fibroids would suggest the need for an alternate method of contraception. Above all, and without exception, smokers should not be taking OCs.

When considering an OC, the pill of choice is one of the new combined, or multiphasic, very low-dose pills. A pill with no more than 35 micrograms of ethinyl estradiol and a consistently low level of progestin, less than one milligram, should be considered. There is actually no persuasive evidence to suggest that one combination pill is better than another as long as you stay with the lowest steroid doses possible that still provide adequate contraceptive protection.

You might consider progestin-only contraceptives, which are being used more often by physicians for their over-forty patients. These are low dose OCs containing no estrogen. As a result, they are appropri­ate for midlife women with gall bladder disease or impaired liver function who would not be candidates for a combined OC. These particular pills are very rarely prescribed for younger women because of their higher failure rate (up to 2 percent) in preventing pregnancy and also because they tend to cause irregular bleeding due to their lack of estrogen. It would appear that the failure rate declines to about 1 percent in women over thirty-five and that older women are also less likely to experience irregular bleeding as a side effect. If all of the above precautions, indications, and clinical observations are carefully followed, older women can safely take birth control pills until the age of menopause and then simply switch to one of the alternate estrogen replacement therapies allowing for a continuum of birth control pill contraception until postmenopausal HRT begins. Of course, the kind of estrogen differs after menopause.

Intrauterine Devices

The intrauterine device (IUD) is an exceptionally good method of contraception despite the adverse publicity it receives. The design, particularly the monofilamentous tail, of the modern types of IUD that are available (like the Copper T or the Progestasert), and the fact that IUDs are being recommended for women over thirty-five who have completed their families, makes this population the most ideal for using this method of contraception. An IUD can be inserted after age thirty-five and changed every four to five years, making it an unobtru­sive, effective, and inexpensive birth control method. The risks as­sociated with the IUD include uterine perforation, which is rare, and pelvic inflammatory disease, which is also rare, particularly in stable monogamous relationships. The failure rates with IUDs in women who are over thirty-five are extremely low and the removal of the device is usually very easy. The IUD is a method that should be considered.

Barrier and Chemical Methods

Methods such as the diaphragm, condom, and spermicides offer realis­tic alternatives for many couples, given the older age of the individual and her consequent decline in fertility. These methods are not fail-proof, and it is wise to consider potential risks of pregnancy. The condom and spermicide (if it contains nonoxynol-9 as its active ingre­dient) are increasingly popular because they may prevent transmission of the AIDS virus. The greater availability and the wide acceptance of the condom makes it a perfectly satisfactory contraceptive choice for women over thirty-five.

Sterilization

Sterilization remains the most frequently chosen method of contracep­tion for women age thirty-five and older. Failure rates are low, but remember this method is permanent and should be undertaken only after you make a well-thought-out decision that you will not later regret. Newer methods of female sterilization have focused on achiev­ing safe, simple tubal occlusion created by placing a silastic (an inert plastic) ring, or clip, on the fallopian tube through an instrument called a laparoscope. It is a short surgical procedure that has few complications and is widely accepted by women.